Please print, fill out, and mail in this form by first class mail so that it is postmarked by August 24, 2005, to ensure adequate time for processing.
Twisted Tea Party
c/o Pacific Media Expo
909 Marina Village Parkway, PMB 660
Alameda, CA 94501
All fields are mandatory except for additional names at the bottom.
Group name:
(Please include pronunciation notes for the Japanese impaired)
______________________________________________________
Project name: ___________________________________________
Project description: _______________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
How many people total will be participating in your project? ___
Are there any minors in your group? ____ If so, how many? ____
*Note: For each minor, the participant's parent or legal guardian must
write a note giving permission.
Full name of your group's primary contact:_______________________
Address, Phone number, and E-mail address of primary contact:
Address: _________________________________________________
_________________________________________________________
Phone___________________(Cell? Y/N) Email: ___________________
Participants (This includes primary contact):
Name: _____________________
Name: _____________________
Name: _____________________
Name: _____________________
Name: _____________________
Name: _____________________